Placement and maintenance of the catheter in the right side of the colon during the entire colonic manometry was achieved in 52% of the patients. Colonic manometry showed normal motility in 40%, abnormal motility pattern in the distal colon in 40%, and colonic inertia was diagnosed in 20% of the patients (Fig. 2).
In 14 patients (56%), both colonic scintigraphy and colonic manometry showed similar results. In 8 patients with a normal manometry, scintigraphy showed a delayed transit time, whereas in 3 patients, the manometry revealed abnormal motility in the distal colon, whereas scintigraphy showed normal transit. All 5 patients diagnosed as having colonic inertia by manometry had similar results with scintigraphy. The calculated sensitivity for scintigraphy was 0.8. The κ score was 0.34, indicating a fair agreement between the 2 studies.
The questionnaire was completed by 25 patients. Data about overall patient and parental preferences demonstrated that 88% of the patients preferred scintigraphy over manometry. Mentioned reasons for this preference included increased comfort, less preparation time, lack of anesthesia, and lack of catheter placement. Scintigraphy was preferred by 60% of parents, manometry by 28% of the parents, and 12% reported no difference between the 2 tests. Parents with a preference for manometry believed that it offered more detailed information and were pleased that it could be accomplished in 1 versus 3 days. The variance in opinions between patients and parents for scintigraphy and manometry was significantly different (P = 0.02). Asked about the experience with both studies, 12% of patients described manometry as significantly unpleasant and 52% of parents expressed concerns about manometry for their child. Reasons for the reported difficulties and concerns with manometry included catheter placement, anesthesia risks, length of study, and discomfort for the child. None of the patients or parents described scintigraphy as unpleasant.
This is the first study comparing the diagnostic yield and tolerability of colonic manometry versus colonic scintigraphy in children with severe constipation. Colonic manometry and colonic scintigraphy had a fair agreement regarding the categorization of constipation. Scintigraphy was well tolerated in pediatric patients and in the majority it was preferred over manometry.
Patients with constipation who do not respond to standard dietary, behavioral, and medical treatments warrant further evaluation to identify the behavioral and physiologic components of their defecatory disorder. Patients with constipation have been traditionally categorized as having normal colonic function, functional outlet obstruction/fecal retention, or colonic inertia/slow transit. Knowledge of the subgroup of constipation may help direct therapy (4,7,18–20). A patient with functional constipation and stool withholding may respond best to laxatives combined with dietary changes and behavioral modifications, whereas a patient with slow transit constipation may benefit from enemas, colonic lavage, or a surgical intervention (4,20). The use of antegrade enemas may be indicated when there is an abnormality limited to distal colon or when the rectosigmoid is dilated. Segmental colectomies can be used when there is a motility disorder involving only a segment of the colon (7).
Although the use of radioopaque markers has been the most common method used to assess colonic transit, it has been suggested that this method may assign markers to incorrect bowel segments and does not provide accurate data on transit through each colonic region (11,21). Also, there is a concern that indigestible solid particles do not move with a meal and may not be handled by the colon in the same manner as stool (22). The disadvantages of scintigraphy are the higher cost compared with radioopaque markers (8) and the inconvenience of having to visit the department 3 days in a row for the acquisition of the images. Comparison of scintigraphy and transit marker studies is difficult because of the different dynamics of the 2 methods (11). Nevertheless, there are a number of studies that have performed simultaneous comparison of radioisotope and plastic markers in healthy adult subjects. These studies show a significant difference in the descending colon, and more patients were diagnosed as having prolonged transit by scintigraphy than by plastic marker study (8,11). Comparison of scintigraphy and transit marker studies for the evaluation of constipation in children has not been performed (23). Some authors argue that scintigraphy is a more reliable technique and should now become the criterion standard in transit studies (11,21).
Our results show that colonic scintigraphy is well tolerated in the pediatric population. None of the patients or parents described scintigraphy as unpleasant. Almost 90% of the patients and 60% of the parents preferred scintigraphy over manometry. Scintigraphy has been criticized for excessive radiation dose (4). The radiation dose given to a patient during a scintigraphy study, however, is equivalent to that of 2 plain abdominal x-rays—the same number of films often used in standard radioopaque marker studies (4,9). There has also been some concern about the short duration of imaging. Although there has been some disagreement about the time period required to assess colonic transit (4,6), functional outlet obstruction has been found to be apparent by 24 to 48 hours, with most of the tracer held up in the rectosigmoid. Determining the total time to excretion would not add any extra useful information, so there is no need to pursue further imaging and unnecessary additional radiation exposure (4).
Colonic manometry is a valuable diagnostic test in providing information about colonic function on a segmental level (7,12); however, the availability of colonic manometry studies is limited to a few pediatric referral centers. Additionally, colonic manometry studies are described as lengthy and somewhat uncomfortable, requiring the use of general anesthesia for the introduction of catheters (23); therefore, the identification of children who would likely benefit from manometry would be helpful (23). On the contrary, during the manometry, parents are able to directly observe the motility tracing and any provocative maneuvers done during the testing. After administration of bisacodyl, for example, many patients experience an urge to defecate. The observation of the child's response to the urge can be enlightening for the parents, who may now recognize stool-withholding behavior that previously they had interpreted as attempts to defecate. These factors make manometry seem more tangible and concrete. Furthermore, during manometry testing, there is continuous presence of the nursing staff or the physician. This may be reassuring to the parents as well (24,25). This is in line with the results of our study, which indicated that despite the expressed concerns, almost 30% of the parents preferred manometry over scintigraphy. All parents were indeed present during the manometry studies in our series.
We found a fair agreement between scintigraphy and manometry and a sensitivity of 80% for scintigraphy compared with colonic manometry. This is comparable with previous studies in healthy adult subjects showing a high sensitivity in the detection of motility disorders of the colon (9,22,26). In this study, colonic scintigraphy identified more patients with abnormal colonic transit, whereas manometry categorized more patients as having normal colonic function. All 5 patients with manometry indicative of slow colonic transit, however, also had scintigraphy studies consistent with slow colonic transit. This suggests that scintigraphy can be used as a screening tool for patients with constipation to determine which patients require additional manometry testing.
Three patients with colonic inertia on scintigraphy had normal manometry studies. Having a diagnosis of colonic inertia has important clinical consequences; therefore, we suggest that an abnormal scintigraphy study suggesting colonic inertia should be confirmed before any medical or surgical treatment choices will be made. In addition, an abnormal colonic scintigraphy even in the presence of normal colonic manometry may have important clinical implications that are presently unclear. Scintigraphy can also provide useful information regarding the proximal colon when the manometry catheter does not reach the proximal colon. Differences between both study results can be related to the fact that patients underwent preparation before colonic manometry. Second, stimulants are used during the study, whereas scintigraphy is done without clean-out and the use of stimulations. The amount of time between the 2 studies had no significant influence on disagreement between both tests. Tipnis et al studied the colonic transit time measured by radioopaque markers and colonic manometry in children with chronic constipation. They found a good correlation between the 2 study results and concluded that, although sensitive, oro-anal transit time was not specific for predicting whether the whole colon or a segment of the colon was affected by either a neuropathic or myopathic disease process. They concluded that transit studies may be helpful to predict which children should be referred for colonic manometry, and that manometric testing remains an important step in the evaluation of children with slow transit constipation (23).
Scintigraphy does have some limitations that warrant further discussion. There is the possibility of capsule malfunction, as occurred in one of our patients. A second limitation is that to date, normative scintigraphy data for children are lacking. There are also age limitations because younger children may not be able to swallow the capsule. Variations in the protocol used for scintigraphy with regard to the number of ROIs as well as the normal values used have been described (27). Although it may not be available at all institutions, scintigraphy could certainly be more available than colonic manometry.
Larger-scale future studies are needed to explore the use of scintigraphy in children, including normal pediatric GC values, possible sex and age differences such as those suggested in previous studies (28), the reproducibility and intrasubject variability (11), the influence of the use of previous medications such as stimulants and stool softeners, and the cost-effectiveness of scintigraphy compared with radioopaque marker studies and manometry.
Colonic manometry and colonic scintigraphy have a fair agreement regarding the categorization of constipation. Scintigraphy is well tolerated in pediatric patients and may be a useful tool in the evaluation of pediatric patients with severe constipation.
The authors thank Laurie A. Gibson and Charmaign Albright for their assistance during the colonic scintigraphy and colonic manometry studies.
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Keywords:© 2013 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,
children; colonic manometry; colonic scintigraphy; constipation